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Spine coding help

  1. #1
    Default Spine coding help
    Medical Coding Books
    PREOPERATIVE DIAGNOSIS:Cervical myelopathy.

    POSTOPERATIVE DIAGNOSIS: Cervical myelopathy.

    1. Third cervical vertebral dome laminectomy.
    2. Fourth cervical vertebra-to-sixth cervical vertebra laminoplasty.

    INDICATIONS FOR PROCEDURE: The patient is a 52-year-old gentleman who
    has been followed by us in the spine clinic for his myelopathic
    symptoms. He presents with positive physical signs of cervical
    myelopathy including clumsiness, ataxic gait, pain radiating down
    bilateral arms, as well as weakness of his intrinsics, biceps, deltoids,
    extensors flexors. Also complicating this situation is that he was
    also diagnosed with bilateral cubital tunnel syndrome which aggravates
    his bilateral upper extremities as well below the level of his elbow.
    After extensive discussion about his dual pathology of his myelopathy
    and bilateral cubital tunnel syndrome, the patient elected to take care
    of his myelopathic issues first since nonoperative management had
    failed. He elected to undergo a C3 dome laminectomy and C4-C6
    laminoplasty. All his questions were answered. The procedure was
    explained in detail so as that the patient could understand. The
    patient signed consent for the procedure, as well as blood transfusion
    as necessary.

    DESCRIPTION OF PROCEDURE: The patient was brought to the operating
    room in stable condition and was induced with general endotracheal
    intubation by the anesthesia team without any complications.
    Subsequently, a Foley catheter was placed, a Mayfield head frame was
    placed on his head, and the patient was positioned in the standard
    prone position with his arms tucked and Mayfield frame attached to the
    bed. He was stable throughout this entire positioning, and the patient
    was prepped in the universal sterile precaution method in his posterior
    cervical region for operative site; 0.25% Marcaine with epinephrine was
    injected into the incision site before the incision was made. The
    incision was brought down from skin down to his cervical spinous
    processes from C3 to C7, and soft tissue was dissected of lamina out to
    the medial edge of the lateral processes from C3 down to C6. All
    bleeding was controlled by coagulation using Bovie, and the level of
    cervical spines were confirmed using lateral cross-table x-ray
    revealing marker on the C3 spinous process. Next, a dome laminectomy
    of C3 was performed using initially rongeur, taking part of the C3
    spinous process off down to the lamina and then using a diamond bur to
    bur down a quarter of the height of the lamina. Subsequently, the
    canal was opened using Kerrisons, and the ligamentum flavum was excised
    out. Then, the spinous interspace between C6 and C7 was rongeured out,
    and the ligamentum flavum was excised as well. The superior aspect of
    C7 lamina was undercut using Kerrisons allowing for breathing room for
    the spinal cord at that level. Once the C3 dome laminectomy and the
    interspinous process between C6 and C7 were prepared, the left side of
    C4, C5, and C6 were burred at the lateral edge of the lamina using a
    diamond bur all the way through the lamina, and the ligamentum flavum
    was cleared using a curved curette. All bleeding was controlled by
    coagulation using the bipolar. Once the left side had been burred all
    the way through, we paid attention to the right side of the lateral
    aspect of the lamina, which was burred through the cortex and
    cancellous bone leaving intact inferior cortex C4 on the right, C5 on
    the right, and C6 on the right. A greenstick fracture was created at
    this junction site on the right, and an open-door laminoplasty was
    created levering up on the open left side of C4, C5, and C6, and
    hinging on the right C4, C5, and C6. The underside of the lamina was
    cleared of all adhesions using a Woodson, and the spinal cord was
    visualized directly and cleared of any adhesions or compressions.
    Next, we used the Medtronic laminoplasty plate system, and 12-mm strut
    plates were used at C6, then C5 and C4. Three screws were used at each
    plate to secure the strut plate down to the lateral process and to the
    lamina of the open laminoplasty. Once again, we visually inspected
    using the Woodson the space available for the cord after the
    laminoplasty was completed, and any bleeding was controlled using the
    bipolar coagulation. A Hemovac was placed to evacuate any collection
    of drainage, and the deep layers were closed with 0 Vicryl, as well as
    the fascia. Then, 2-0 Vicryls were used to close the subdermal region,
    and Monocryl was used to close the skin in a plastic surgery manner.
    Subsequently, a closing confirmatory lateral x-ray was taken to make
    sure that we were completed at the correct levels, and no
    instrumentations were retained within the wound. The wound was dressed
    in Dermabond, 4 x 4 sterile gauze, and tape. The patient was stable
    throughout the entire procedure and was extubated without

    Would this be coded as 63051 not sure??
    Last edited by EMS7775; 06-30-2009 at 11:02 AM.

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